Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 6471 | OK |
NPI | 1003347048 |
---|---|
Provider Name | Alyssa Penick |
First Address | Oklahoma City, OK 73102-1015 |
Second Address | Oklahoma City, OK 73102-1015 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2017 |
Last Update Date | 10/01/2019 |